Range of motion exercises in the setting of burn-associated heterotopic ossification at the elbow: case series and discussion

A scoping review on active vs. passive range of motion approaches to treat heterotopic ossification at the elbow

Objective

The objective of this scoping review is to synthesize and clarify literature on the effectiveness of active and passive range of motion therapy techniques to address range of motion in people with heterotopic ossification (HO), and to provide guidance to therapists in clinical decision-making based on current evidence.

Method

To find articles that included therapeutic interventions to maintain or improve range of motion in people with heterotopic ossification, the authors searched the following databases: Cochrane Database of Systematic Reviews, PubMed, CINAHL, PsychINFO, Web of Science, and OTSeeker. To ensure that the search was comprehensive, the authors also searched Burns and Trauma, Burns Journal, Burns Open, and the Journal of Hand Therapy. Searches were limited to peer-reviewed articles published in the English language. No publication date limits were set. The Physiotherapy Evidence Database PEDro scale was utilized to measure the validity of the methodological quality of each article.

Results

Five studies met the inclusion criteria.. Two studies emphasized that passive range of motion was effective in less than 50% of their subjects, while the other three studies utilized active range of motion only, reporting 50% of patients did not require surgery.

Discussion/conclusion

There is insufficient evidence to determine effective therapeutic management of HO and the literature that does exist is contradictory and inconclusive. Future research is necessary to determine if any effectiveness of manual therapeutic approaches exists for patients with HO.

Burn Injury Complications Impacting Rehabilitation

Successful post-burn rehabilitation requires an understanding of a wide range of complications to maximize functional recovery. This article reviews a range of potential challenges including burn scar contracture, amputation, peripheral nerve injury, heterotopic ossification, dysphagia, altered skin physiology, pain, and pruritis. The overall focus is to serve as a guide for post-injury therapy and rehabilitation spanning the phases of care and considering evidence-based approaches, prevention, and treatment with an ultimate goal of aiding in the functional recovery and long-term quality of life for burn survivors.

Anterior Elbow Heterotopic Ossification in Patient With Pemphigus Vulgaris: An Unheard Complication of a Rare Condition

Pemphigus vulgaris is a potentially fatal disease within the epidermis with rare noncutaneous manifestations. Heterotopic ossification has not been previously described as one of the inherent complications of this skin pathology. A 44-year-old man presented with severe pemphigus vulgaris involving 80 to 90% of his body surface area. He had an extended time to wound closure of 5 months, as well as two additional months bed bound due to related infectious and respiratory complications. He progressively developed a worsening range of motion at his bilateral elbows. X-ray demonstrated bilateral anterior elbow heterotopic ossification. Passive and active range of motion exercises were initiated early in the course of his treatment and only yielded a small positive effect. Thus, screening for heterotopic ossification may be warranted when a significant joint range of motion is lost in cases of autoimmune cutaneous disease, and even more in the presence of severe open wounds with delayed wound closure.

Heterotopic Ossification: Clinical Features, Basic Researches, and Mechanical Stimulations

Heterotopic ossification (HO) is defined as the occurrence of extraskeletal bone in soft tissue. Although this pathological osteogenesis process involves the participation of osteoblasts and osteoclasts during the formation of bone structures, it differs from normal physiological osteogenesis in many features. In this article, the primary characteristics of heterotopic ossification are reviewed from both clinical and basic research perspectives, with a special highlight on the influence of mechanics on heterotopic ossification, which serves an important role in the prophylaxis and treatment of HO.

A Comparison of Contracture Severity at Acute Discharge in Patients With and Without Heterotopic Ossification: A Burn Model System National Database Study

This study assesses the association between heterotopic ossification and upper extremity contracture by comparing goniometric measured active range of motion outcomes of patients with and without heterotopic ossification. Data were obtained from the Burn Model System National Database between 1994 and 2003 for patients more than 18 years with elbow contracture at acute discharge. Absolute losses in elbow range of motion were compared for those with and without radiologic evidence of heterotopic ossification (location undefined) and were further examined by burn size subgroups using Wilcoxon rank-sum test. Differences in elbow range of motion were estimated using regression models, adjusted for demographic and clinical variables. Loss of range of motion of shoulder, wrist, forearm, and hand were also compared. From 407 instances of elbow contracture, the subjects with heterotopic ossification were found to have greater median absolute loss of elbow flexion among all survivors (median 50° [IQR 45°] vs 20° [30°], P < .0001), for the 20 to 40% total body surface area burn subgroup (70° [20°] vs 20° [30°], P = .0008) and for the >40% subgroup (50° [45°] vs 30° [32°], P = .03). The adjusted estimate of the mean difference in the absolute loss of elbow flexion between groups was 23.5° (SE ±7.2°, P = .0013). This study adds to our understanding of the potential effect of heterotopic ossification on upper extremity joint range of motion, demonstrating a significant association between the presence of heterotopic ossification and elbow flexion contracture severity. Further study is needed to determine the functional implications of heterotopic ossification and develop treatment protocols.

Surgical treatment of postburn heterotopic ossification around the elbow: Three case reports

RATIONALE

Heterotopic ossification (HO), which is defined as the formation of new bone in tissues that do not normally ossify, is an infrequent yet debilitating complication of burns. Herein, we report three patients who suffered from elbow HO after burn injury due to a dust explosion event. This is a case report that includes the most cases involved in a single mass casualty incident in the presented literature.

PATIENT CONCERNS

Case 1: A 28-year-old man presented with second-to-third degree 88% total body surface area (TBSA) burns after the explosion event. He complained of decreased progressive bilateral elbow range of motion (ROM) for 1.5 months after the burn injury.Case 2: A 28-year-old woman presented with second-to-third degree 50% TBSA burns and complained of decreased progressive bilateral elbow ROM with intolerable pain on elbow extension for 1 month after the burn injury.Case 3: A 22-year-old man presented with second-to-third degree 90% TBSA burns and complained of significantly decreased left elbow ROM with intolerable pain 5 months after the burn injury.

DIAGNOSIS

The follow-up radiograph of the symptomatic elbow of these three patients revealed heterotopic ossification formation. Three-dimensional reconstruction computed tomography performed preoperatively showed that HO mainly affected the humeroulnar joint.

INTERVENTIONS

We treated all three patients with surgical elbow HO resection and ulnar nerve transposition, followed by immediate passive ROM exercise since postoperative day 1 and continuous physical therapy.

OUTCOMES

In case 1, the documented ROM gain on the last follow-up (18.5 months after surgery) was 30° in the right elbow and 118° in the left elbow. In case 2, the follow-up time was 21 months and the documented ROM gain on the last follow-up was 120° in the right elbow and 90° in the left elbow. In case 3, the follow-up time was 20 months and the documented left elbow ROM gain on the last follow-up was 40°.

LESSONS

We discuss our experience of treating postburn HO and review the recent literature. The postburn HO treatment results of early surgical excision combined with immediate postoperative physical therapy were satisfactory.

Two new risk factors for heterotopic ossification development after severe burns

Objectives

Life after severe burns is conditioned by the remaining sequelae. The pathophysiology and risk factors of Heterotopic Ossification (HO) after burns are still poorly understood. The aim of this study was to determine: 1) the incidence of HO after burns and 2) the risk factors associated with HO development, in a large retrospective study.

Methods

A case-control study of patients admitted to the burns intensive care unit of Percy Hospital, Paris, from the 1^st January 2009 to the 31^st December 2013 and then admitted to one of three centres specialised in the rehabilitation of patients with burns. Multivariate analysis was carried out to analyse the relationship between HO development and demographic and clinical data.

Results

805 patients were included. 32 patients (4.0%) developed a total of 74 heterotopic ossifications, that is a little higher incidence than the incidence found in the literature. The epidemiological characteristics of the population studied was similar to the literature. HOs were mainly localized around the elbows, followed by the hips, shoulders and knees. Each case-patient was paired with 3 control-patients. There were significant associations between HO development and the length of stay in the burns intensive care unit, the extent and depth of the burns, the occurrence of pulmonary or cutaneous infections, use of curare and use of an air-fluidized bed.

Conclusion

In addition to recognized risk factors (duration of stay in the intensive care burns unit, extent and depth of burns, pulmonary and cutaneous infections), the use of curare and the use of a fluidized bed (with the duration of use) were significantly associated with HO formation.

Acquired heterotopic ossification of the temporomandibular joint

Although the risk factors and diagnosis of heterotopic ossification (HO) are discussed in the orthopedics literature, the etiology of HO, as well as its prevention and management, remain theoretical. Furthermore, there is a lack of information in the literature regarding HO in temporomandibular joint replacement (TMJR). This article provides a qualitative review of information relative to the etiology, diagnosis, and management of HO to inform and encourage further investigation in TMJR. The orthopedic HO literature considered for this qualitative review was drawn from a comprehensive examination of the subject published previously by one of the authors. Using the key words "heterotopic ossification" or "heterotopic bone", citations in the PubMed database from both the dental and oral and maxillofacial surgery literature were reviewed. Based on this, it appears that the etiology, diagnosis, imaging, laboratory testing, risk factors, prophylaxis, and non-surgical and surgical options available for the management of TMJR-related HO are similar to those for orthopedic HO, but further elucidation is required for TMJR. There is a lack of published information in the literature on TMJR. Therefore, using the literature from this review as a foundation, studies should be developed and reported so that alloplastic TMJ surgeons have evidence-based protocols that will lead to the early detection and potential prevention of HO.

Heterotopic Ossification in adults following a burn: A phenomenological analysis

Heterotopic Ossification (HO) is a rare but severely debilitating complication after a burn. Despite there being literature of varying quality explaining the postulated pathological process, risk factors and treatment for HO, the individual experiences of adults diagnosed with HO following a burn, remains unreported. This study sought to explore and describe burn survivors' experiences of HO to gain a greater understanding of the clinical needs for this unique patient population. A phenomenological inquiry of five men and one woman selected through purposeful sampling collected in-depth interviews analysed using Colaizzi's method of data analysis. Five emergent themes: (1) Early signs and symptoms, (2) Impact on the rehabilitation journey, (3) The role of the health care professionals (4) Loss of independence and an increased reliance on others and, (5) Learning to live with it: uncertainty, hope and adaptation. Eleven cluster themes were identified, highlighting the meaning of each emergent theme. These findings describe the significant impact the unique symptomology of HO had on the physical and psychosocial functioning of participants throughout the rehabilitation journey. Central to engagement in rehabilitation, is the participants' desire for autonomy particularly in the domains of living independently and community re-integration.

The development and impact of heterotopic ossification in burns: a review of four decades of research

Background to this subject:

Heterotopic ossification (HO) is the formation of bone within the tissue where bone should not form and is a rare complication after burn injury. However, it leads to severe pain and distress, marked reduction in joint range of motion (ROM), impaired function and increased hospital length of stay. The pathophysiology, incidence and risk factors of HO remain poorly understood in burns and other traumas and the management, controversial.

Question being asked or issue explored:

The aim of this comprehensive review was to synthesise the available evidence on the development and treatment of HO after acute burn injury.

Details of how the work was conducted:

The review was based on a systematic search of medical electronic databases to identify relevant published literature.

What we did and did not learn from this study:

Synthesis and analysis of the data highlighted that, despite the passage of time, little translatable evidence is available to guide any prevention, screening, diagnostic or pharmacological or physical management protocols. Causes of HO remain confounded, therefore prevention is difficult. Although spontaneous resolution is possible, surgical resection remains the recommended treatment when ROM and activities of daily living are severely affected. The findings from this review indicate that multicentre data pooling is needed to understand the optimum pathway to prevention, identification and treatment of HO in acute burn patients.

Corrective and reconstructive surgery in patients with postburn heterotopic ossification and bony ankylosis: an evidence-based approach

Articular heterotopic ossification (HO) and subsequent bony ankylosis (BA) are infrequent yet devastating complications of severe burn injuries. These conditions are diagnosed clinically and confirmed by imaging. Patients then begin active physical therapy until cleared for surgery, which remains the standard of care. This study critically reviews the existing literature on the diagnosis, treatment, and surgical outcomes of HO/BA in severely burned patients and provides an evidence-based treatment algorithm. A comprehensive search for all the studies addressing HO and BA after burn injury was conducted using PubMed and Google Scholar from 1957 to 2013. Fifty-one studies on postburn HO/BA have been published, reporting incidences from 0.1 to 35.3%. Most patients suffered from third-degree, thermal burns, with a mean TBSA of 49 ± 14%. The mean time from burn until diagnosis was 7 ± 11 months. Seventy-nine percent of the affected joints were elbows and 84% had adjacent and/or overlying burns. Ninety-one percent of joints had solely extra-articular HO. Ninety percent of HO/BA cases were treated with anatomic excision, and all achieved appreciable increases in range of motion with infrequent recurrence. Perioperative radiotherapy was used infrequently. Surgical articular reconstruction is the standard of care for postburn HO/BA severe enough to limit joint movement and/or function. Early detection and initiation of physical therapy are paramount in preventing progression to complete BA. Increased awareness and more rapid means of detecting postburn articular changes may permit earlier discontinuation of passive range of motion exercises, thereby halting the initiation and progression of HO.

Heterotopic Ossification: Basic-Science Principles and Clinical Correlates

➤ Heterotopic ossification occurs most commonly after joint arthroplasty, spinal cord injury, traumatic brain injury, blast trauma, elbow and acetabular fractures, and thermal injury.➤ The conversion of progenitor cells to osteogenic precursor cells as a result of cell-mediated interactions with the local tissue environment is affected by oxygen tension, pH, availability of micronutrients, and mechanical stimuli, and leads to heterotopic ossification.➤ Radiation and certain nonsteroidal anti-inflammatory medications are important methods of prophylaxis against heterotopic ossification.➤ Well-planned surgical excision can improve patient outcomes regardless of the joint involved or the initial cause of injury.➤ Future therapeutic strategies are focused on targeted inhibition of local factors and signaling pathways that catalyze ectopic bone formation.